Reaching Down the Rabbit Hole (26 page)

“Go ahead, Trey, and I’ll watch and record.”

But before we could begin, Elliott walked in, always to be depended on to get us coffee whether we want it or not, sometimes appearing out of nowhere with a nugget of information, whether we want it or not.

“He’s a pervert you know,” he said.

“What the hell are you talking about?” I replied.

“Nancy, the swing nurse, told me. He lives in her neighborhood in Malden, and everyone went ballistic when he moved in. He’s a child molester.”

“Jesus Christ!”

Trey gave me a long, probing look. I pinched the bridge of my nose hard between thumb and forefinger. As if on cue, Elliott grabbed his coffee, puffed out his cheeks in self-exoneration, and, with a baleful grin said, “Well . . . enjoy!” And he left.

Trey turned to me and said, “Okay, so is he dead
now
?”

Knowing when someone’s alive and knowing when someone’s dead: it’s one of the most important jobs that doctors do. If we can’t do that, we can’t do anything.

Marty’s words kept ringing in my head. It is one of our most important functions, and in most cases, it is unambiguous: death by cardiac criteria is a well-established standard that applies to the vast majority of patients who die in a hospital, or en route to a hospital, or at home. Death by brain criteria is another story.

When my department chairman, Raymond Adams, agreed to serve as the only neurologically experienced physician on a committee headed by Dr. Henry K. Beecher from the Harvard Medical School in 1968, he expected little controversy. The group was convened by the dean of the Medical School to look into establishing ways of determining whether a coma could be deemed irreversible, thus the title of the paper they produced: “A Definition of Irreversible Coma.” The dean also anticipated little criticism, but there was a storm of outrage from the Catholic Church and from many physicians and philosophers because of the paper’s first sentence: “Our primary purpose is to define irreversible coma as a new criterion of death.” It was instantly recognized that there could be a conflict of interest from the emerging field of organ transplantation, which had originated at the Brigham in 1954, when Nobel Prize winner Joseph Murray performed the first successful kidney transplant.

It was partly in response to the advent of organ transplantation that the Vatican began looking into the issue of brain death in the early 1960s. The Beecher Committee report caught the College of Cardinals off guard, but it became the touchstone for all that has happened since. In 1981, a presidential commission codified the Beecher Committee’s finding as the Uniform Determination of Death Act, establishing the justification for organ retrieval as death by “whole brain criteria,” or “the irreversible cessation of all functions of the entire brain.” The imprimatur of Harvard Medical School and a presidential commission did not resolve the question, as it turned out. The Beecher Committee concluded that “medical opinion is ready to accept new criteria for pronouncing death to have occurred in an individual sustaining irreversible coma as a result of permanent brain damage.”
The Presidential Commission said, “We are going to define death of the whole brain as the death of the organism.” But as at least one critic would note, “brain death is a conclusion in search of a justification.”

Medicine on the whole has no trouble making the determination of brain death. That is a technical matter. The nagging issue is whether a warm, pink, pulsating, live-looking body can or should be called dead. All of the organs are viable. The body could go through the onset of puberty, it could gestate an infant. There are such cases on record. What the Beecher Committee accomplished was to find a good reason not to utilize resources on people who would unquestionably die without ever regaining consciousness. Being able to change their classification and call them dead had virtue for society. They said, in effect, “It’s not living if your brain is irrevocably gone; it’s not living, so you can go ahead and take the organs.”

They had a clear mandate to protect the physician. They recommended, for example, that the patient be declared dead before the respirator is disconnected, so as to avoid the appearance of pulling the plug on a living person. They also recommended that any physicians involved in transplanting the organs recuse themselves from the decision process. But they were guided by practical motives, not strictly scientific ones, and the legacy of the Beecher Committee and the Presidential Commission have now trapped us. What somebody needed to say was: we’re going to have a societal shift, and if your brain is so irrevocably and totally damaged that there is no hope of recovery, and it’s total (so that there won’t be any quibbling), then the patient is in a state where it is reasonable to do organ transplants. Calling it death was the problem.

In a moment of great clarity, the Catholic Church signed on to the idea that brain death is death. In 2006, I served on the panel of the Pontifical Academy of Sciences at the Vatican that produced a monograph entitled: “The Signs of Death.” We discussed every angel one could fit on the head of a pin, including whether “death” meant that every cell in the body must be dead, an obvious extreme given that hair
and nails continue to grow after death. The monograph began with a quote from St. Augustine:

Thus, when the functions of the brain, which are, so to speak, at the service of the soul, cease completely because of some defect or perturbation—since the messengers of the sensations and the agents of movement no longer act—it is as if the soul was no longer present, and was not in the body, and it has gone away.

In the end, the church adopted the view that brain death is death, and reaffirmed Augustine’s basic and ancient view, while reserving a place for the soul separate from the body. And yet within the Church there remain strong opponents of this brain-death perspective, even of removing organs from the brain dead, and these forces are again beckoning at the pope’s door.

I once had a patient, a member of Hell’s Angels, who was shot in the face while driving his Harley down the interstate at eighty miles per hour—with a shotgun, no less—who then went off the road and creamed his entire cranium (no helmet), and was quite obviously brain dead. Some of his brain matter was left on the road. They might as well have decapitated him, except that when he was placed on a ventilator—intubated—his heart still pumped and the body was kept alive. Here was this outlaw, a tough guy, maybe a sociopath, and ironically, it said “organ donor” on his driver’s license. In the end, he turned out to be a humanitarian.

There was no question of transplanting his corneas. They were no longer there, and that was the problem: How do you know a person like that
is
brain dead without the all-disclosing eyes? We couldn’t examine his pupils. We couldn’t examine his eye movements or his corneal reflexes. I recall thinking,
Oh my God, you don’t want to get a diagnosis of brain death wrong because it would be like committing an innocent man to the electric chair. How am I going to finesse this?

We could show that he had apnea (that he couldn’t breathe on his own), but that’s just one of the five elements of the tests for death by brain criteria. The Presidential Commission said that in certain circumstances you can use surrogate tests. So we did an EEG. He had barely enough scalp on which to place the leads, and the readout was flat, or, in tech-speak, isoelectric. We did a cerebral blood flow scan. The examination took hours, not because his face was blown off, but because I had a tough time persuading the nuclear medicine people to come in and do the test at night for a dead guy. They said, “We’ll come in and do it in the morning.”

I said, “They don’t want to lose his organs. Come in now.”

They said, “Oh, c’mon!”

“No, get your ass in here and do it or I’ll keep kicking it up the chain until somebody does.” Finally their man came in, injected technetium, a radioactive element which circulates to show if there’s any blood going into the brain. There wasn’t.

No one agonized over the case, possibly because the biker no longer had eyes, unlike Marty’s example of the dog hit by the car. There wasn’t much left of him as a recognizable person. But inside, he possessed pristine organs that did an inconceivable amount of good, perhaps even a redemptive amount of good.

Could we say the same for Mike Kavanagh?

“By the way . . .” I said to the head ICU nurse.

“Yes, I know,” she interrupted, coldly finishing my thought, “he’s a donor.”

The news about Mike’s past had spread instantly, and a pall had settled over the unit. Once someone is pegged as brain dead, the collective investment of psychic energy in the presence of the body deflates, the motivating principle resets, and that patient becomes marginalized on the ward. A rescue mission becomes a salvage mission: we’re just preserving organs. But around Mike the child molester, after the initial shock wore off, the effect became palpable. Staff people walked around
the entrance to his room in an arc, as if there were cold air coming out of it. His very presence was an insult. Everyone wanted it to be somebody else’s problem, but it was ours.

“How about that, Trey? The guy was an angel.”

Trey harrumphed, reached under the covers, and pinched the skin on Mike’s abdomen.

“Jesus, Trey! A bit coarse, don’t you think?”

“Sorry, but it’s better than twisting his nipples.” He was referring to an obsolete practice from my generation of neurologists, now roundly considered utterly barbaric. The pinch elicited no movement, not even a brief jerk of the torso or limbs. Next came a more conventional and ostensibly more humane stimulus of applying serious pressure on a knuckle of each limb using the shaft of a reflex hammer, the neurologist’s favorite weapon. Women neurologists, I have noticed, tend to press harder than men, as if to insure that no one is getting out alive. In this instance there was not a whit of movement. All but a fully paralyzed, comatose patient would exhibit a straightening of the arms and pushing backward as the shoulders rotate internally. But here: nothing, no cerebral response.

Trey then peered in at the pupils. “Round, eight millimeters,” he shouted.

“Did you measure or are you guessing?” Up went Trey’s eyebrows and out came a round laminated pupil gauge with a series of black circles of increasing size. Trey held it up to the patient’s eye.

“Okay,
seven
millimeters and not reactive.” The midbrain could now be checked off the list, given that it controls pupillary size and reaction to light.

“Ambiguous,” I said. If the pupils are too small or too big, they indicate a remnant of brain function in the pons. Nine millimeters would have been unusual in a true case of brain death. Seven was okay, but not conclusive.

“Do you want me to do calorics or doll’s eyes?” Trey asked, referring to two methods of making the eyes move from one side to the
other, thereby testing the integrity of the pons, the middle part of the brain stem. Because the patient had a collar on, and might have a broken neck, we couldn’t move his head from side to side, so we did the caloric reflex: squirting ice water into one ear, then the other. This provides a potent stimulus to eye movements through a hardwired circuit in the brainstem, if it’s functioning at all.

“Nada.”

Now the moment of truth, the apnea test. Will he breathe? “How do you like to do it, Dr. Ropper?”

“Preoxygenate him.”

The person must have an apnea test. Then you can prove to yourself that the whole brain, including the brainstem, is gone. Just remember, when you take a patient off a ventilator, either for an apnea test or after a declaration of death, make sure that family members are out of sight, and forewarn the nurses. Many brain dead patients, once the ventilator is removed, exhibit the so-called Lazarus sign, where their arms spontaneously contract and their hands come up to their chest as though they’re grasping for the endotracheal tube. It’s creepy no matter how many times you’ve seen it.

This test is the big one. It grew out of Moses Maimonides’ practice of holding up a glass to see if the breath fogs it. The object is to see whether the patient will breathe on his own. We sent 100 percent oxygen through Mike Kavanagh’s lungs for two minutes, enough to sustain his heart and blood pressure without a ventilator for the next ten minutes, then shut off the ventilator.

Silence. I could hear my pocket watch ticking. As Trey and I watched closely, we could see a few arching movements in Mike’s back, definitely not Lazarus signs, but something not entirely compatible with brain death. We waited. With the palm of my hand acting as Maimonides’ mirror, I felt air moving almost imperceptibly in
and out of the ventilator tube. Was he breathing? Trey was convinced that he wasn’t, but he was already convinced that the guy was dead. It was important to be sure.

It can be useful to have a nemesis, ideally an arch-nemesis. Mine is Shewmon. Although not really my nemesis, he is a real person with a point of contention that has pitted us against each other for more than a decade.

Alan Shewmon, a respected neurologist and professor at UCLA Medical Center, has the audacity to claim that brain death is not death. He didn’t always believe this, but his worldview changed about a decade ago when he was presented with a patient, a fourteen-year-old boy, who suffered a severe head trauma after jumping onto the hood of a slow-moving car, falling off, hitting his head on the curb, and eventually being confirmed as brain dead. Yet he “lived” for another sixty-three days on a respirator and vital fluids. Dr. Shewmon was called in to examine the boy, and he agreed with the brain death determination. By the standards of the State of California, the boy was a corpse, but at the family’s insistence, the body was kept going in a facility under the care of nurses who were baffled and unsettled by that diagnosis. Shewmon reported that the boy began to go through puberty and eventually died, not from his head injury, but of pneumonia.

How long can a body survive in a brain-dead state? Not indefinitely, but longer than most people think. That is Shewmon’s central point: How do we classify such a body, because death by brain criteria is not the same as death of the biological organism? It might well be considered death by psychological, sociological, legal, or religious standards, but as Shewmon notes, if you brought a biologist into the nursing facility to see the fourteen-year-old boy, and, telling him or her nothing else, simply asked whether this was a living organism or a dead organism, any biologist would have to say that the boy was alive—severely compromised, but living.